中华胃肠外科杂志最新文献

Objective: To explore the impact of neoadjuvant immunotherapy on the occurrence of low anterior resection syndrome (LARS) in patients with locally advanced rectal cancer who underwent restorative anterior resection, and to analyze associated risk factors. Methods: This study was an observational study. Patients with adenocarcinoma, mucinous adenocarcinoma, or signet ring cell carcinoma of the rectum located 0-10 cm from the anal verge who received neoadjuvant immunotherapy followed by curative restorative anterior resection at Peking University Cancer Hospital between November 2019 and February 2024 were retrospectively examined. Exclusion criteria were as follows: (1) metastasis detected preoperatively;(2) follow-up <1 year or stoma closure <6 months; (3) local recurrence or metastasis during follow-up; and (4) stoma without closure or stoma re-creation. The Chinese version of the LARS questionnaire was used to assess bowel function by telephone interview, and patients were classified based on score into no LARS (0-20 points), minor LARS (21-29 points), and major LARS (30-42 points). The incidence of LARS, major LARS, and associated risk factors were analyzed. Results: A total of 52 patients (34 men) were included for analysis. Mean age was 58.0 ± 9.8 years and mean body mass index was 25.1 ± 2.6 kg/m². Median follow-up was 27.5 months (range, 12.0-63.7). Median LARS score was 21 (range, 1-41). Twenty-six patients (50.0%) developed LARS after surgery, and half of these (13 cases) were classified as major LARS. Stool clustering (repeated defecation within 1 hour) was observed in 80.8% (42/52) of patients. Distance between the tumor edge and the dentate line [odds ratio (OR), 3.597; 95% confidence interval (CI), 1.140-11.360; P=0.026], management of the left colic artery (OR, 0.133; 95% CI, 0.026-0.691; P=0.008), and interval of stoma closure (OR, 5.250; 95%CI, 1.381-19.960; P=0.011) were significantly associated with LARS. Interval of stoma closure was significantly associated with major LARS (OR, 4.200; 95%CI, 1.064-16.584; P=0.040). In multivariate logistic regression, ≤3.5 cm between the tumor edge and the dentate line (OR, 7.407; 95%CI, 1.377-40.000; P=0.020), non-preservation of the left colic artery (OR, 8.403; 95%CI, 1.183-58.823; P=0.033) and interval of stoma closure >6 months (OR, 10.865; 95% CI, 2.039-57.896; P=0.005) were independent risk factors for LARS. Interval of stoma closure >6 months (OR, 4.356; 95% CI, 1.105-17.167; P=0.035) were independent risk factors for major LARS. Conclusion: Patients with locally advanced rectal cancer treated with neoadjuvant immunotherapy experienced a high incidence of LARS after curative surgery, with stool clustering as the predominant symptom. Tumor edge-dentate line distance ≤3.5 cm, non-preservation of the left colic artery, and interval of stoma closure >6 months were risk factors for LARS.

Objective: To compare the short-term outcomes and cost-effectiveness of laparoscopic and open ileostomy reversal. Methods: A retrospective cohort study was adopted. Clinical data of patients who underwent loop ileostomy reversal at the department of Colorectal Tumor Surgery of Shengjing Hospital Affiliated with China Medical University from January 2021 to November 2023 were reviewed. After excluding those who did not undergo reversal within 3 to 6 months of the initial surgery, patients with complications such as parastomal hernia requiring additional procedures, and those who underwent laparoscopic-to-open conversion, 150 were included for analysis. Patients were grouped according to type of reversal: open surgery (92 patients) and laparoscopic (58 patients). The primary outcome was cost-effectiveness. The success rate of ileostomy reversal was used as the health outcome. Hospitalization costs were collected via the hospital information system. The willingness-to-pay (WTP) threshold was set at three times the per capita gross domestic product. Differences in cost and success rates between open and laparoscopic procedures were compared. Incremental cost per successful reversal of ileostomy reversal and incremental cost-effectiveness ratios (ICER) were calculated (ICER < WTP indicates that laparoscopic ileostomy reversal is more cost-effective than open). Results: Compared with open reversal, the intraoperative blood loss volume was lower[ (35.5±12.6) ml vs.(57.7±19.0) ml,t=7.874, P<0.001] ; adhesion release rate was higher [82.8%(48/58) vs.46.7%(43/92), χ²=19.341, P<0.001]; time to first flatus [(99.4±32.4) hours vs.(115.0±35.3) hours, t=2.734, P=0.007] and time to unassisted ambulation [42(18-71) hours vs. 51(25-78) hours, Z=-6.440, P<0.001] were earlier; postoperative hospitalization was shorter [(12.0±3.4) days vs.(15.0±3.6) days, t=5.010, P<0.001] ; visual analog scale pain score on postoperative day 2 was lower [3(3-4) vs. 4(4-4), Z=-6.488, P<0.001;3(2-3) vs. 3(3-4), Z=-4.810, P<0.001]; and incidence of postoperative complications was lower [8.6%(5/58) vs. 21.7%(20/92), χ²=4.408, P=0.036] in the total laparoscopic group. The ICER of the total cost of the laparoscopic group relative to the open group was 38 221.89 CNY. Univariate sensitivity analysis showed that the success rate of laparoscopic reversal had the greatest impact on the results. The cost-effectiveness acceptability curve showed that when the WTP was 257 094 CNY, the probability of laparoscopic reversal being economical was 84.9%. Conclusion: Laparoscopic ileostomy reversal is more cost-effective than open and has superior short-term outcomes.

Transabdominal and transanal endoscopic approaches have become mainstream in colorectal surgery. With the substantial improvement in survival outcomes for colorectal cancer patients, a growing number of colorectal surgeons are increasingly focusing on enhancing postoperative quality of life, prioritizing functional preservation, especially the intraoperative preservation of pelvic autonomic nerves. Recently, with the gradual deepening of artificial intelligence (AI) applications in the medical field, colorectal surgeons have begun exploring its implementation in colorectal surgery. Current achievements primarily involve the identification and protection of nerves and organs. However, most AI applications remain at preclinical exploration stages, limiting their clinical application. Furthermore, AI faces challenges in recognizing blood vessels with significant deformation and movement. Thus, the precise real-time navigation and protection of blood vessels during surgery have yet to be achieved. Therefore, future developments in this field should focus on resolving issues such as non-rigid registration, real-time calibration etc., thereby deepening the application of AI in functional preservation and surgical safety assurance during laparoscopic colorectal surgery.

Objective: To explore the application of the camera inversion technique in laparoscopic sphincter-preserving surgery for mid to low rectal cancer. Methods: A retrospective study with historical controls was conducted on patients with non-metastatic mid to low rectal cancer which received laparoscopic total mesorectal excision at Peking Union Medical College Hospital from January 2019 to June 2024. The experimental group (2021.7-2024.6) utilized the camera inversion technique (rotating the lens 180° to position the bevel upward and switching the system to reverse display mode for improved visualization and operative angles) during key surgical steps (such as intraoperative mobilization of the mid-to-lower rectum and anastomosis), while the control group (2019.1-2021.6) did not. Clinical data and surgical videos were collected to analyze indicators like operative time, blood loss, mesorectal integrity, surgical complications, and postoperative hospital stay. Results: A total of 624 patients with non-metastatic mid to low rectal cancer were included, including 412 males and 212 females, with an average age of 59.8 years and an average tumor distance of 5.6 cm from the anal verge. The experimental group comprised 301 patients, while the control group had 323 patients.The proportion of abdominal ISR (intersphincteric resection) was significantly higher in the experimental group [19.3% (58/301) vs. 10.2%(33/323), χ²=10.140, P=0.001], with a reduction in operative time [(161.8±67.8) minutes vs. (150.2±68.5) minutes, t=2.134, P=0.033] and a decrease in postoperative hospital stay [(7.8±2.1) days vs. (8.3±3.4) days, t=2.003, P=0.046]. The experimental group also demonstrated advantages in intraoperative blood loss, mesorectal integrity rate, and postoperative complications such as urinary retention, though these differences were not statistically significant (all P>0.05). Conclusion: In laparoscopic surgery for mid to low rectal cancer, using camera inversion technique during distal rectum dissection and transanal anastomosis can provide better surgical field exposure, facilitate precise operations within the correct anatomical plane, and minimize collateral damage. The camera inversion technique is safe and effective.

Low anterior resection syndrome (LARS) is a series of symptoms of intestinal dysfunction, and its research is mainly focused on patients with low rectal surgery. However, with the deepening understanding of postoperative LARS, surgeons found that LARS not only exists among patients who have undergone low anterior resection of rectum, but also plagues a considerable number of patients who have undergone non-rectal (mainly colon) surgeries. This article aims to elaborate on the incidence and treatment of LARS after colon surgery. Through a comprehensive analysis of relevant studies, it is found that the incidence of LARS after colon surgery is approximately 20%-30%, and the incidence is relatively higher in patients undergoing right hemicolectomy. Its pathogenesis is related to multiple factors, including surgical methods, resection range, changes in intestinal flora, patient age, gender, and underlying diseases. Treatment methods include conservative treatments such as dietary adjustment, drug therapy, transanal irrigation, and rehabilitation training. Single treatment methods have limited effect, while comprehensive treatment can effectively improve patients' symptoms and quality of life. The current LARS scoring system has not been effectively verified in the application after colon cancer surgery, and it is necessary to develop a more targeted scoring system.

With the advancement of rectal cancer surgery, low anterior resection syndrome (LARS) has emerged as a significant issue impacting the postoperative quality of life for patients. Anorectal manometry (ARM), an essential diagnostic tool, possesses principles and methodologies that are crucial for assessing anorectal function. In the context of LARS diagnosis, ARM plays a pivotal role by providing objective evidence for clinical evaluations. Concurrently, the implications and efficacy of this technology in treatment are gaining increasing attention. Nonetheless, several challenges remain regarding its current application. Through an analysis of existing research, this article aims to elucidate the value of ARM in both the diagnosis and treatment of LARS, with the ultimate goal of enhancing the diagnostic and therapeutic approaches to LARS and improving patients' quality of life.

With the development of surgical techniques, adjuvant therapy and neoadjuvant therapy, the survival time of rectal cancer patients after surgery has been significantly improved, but organ dysfunction is still an important problem affecting the quality of life of patients after surgery. With the continuous deepening of clinical research and practice and the updating of relevant theories, more detailed and reliable evidence-based medical evidence has been accumulated in the field of pelvic organ function protection in rectal cancer surgery, and has been continuously verified in the clinical real world at home and abroad. In order to further improve the awareness of domestic physicians on the protection of organ function during the treatment of rectal cancer, standardize the evaluation methods and surgical methods, reduce the incidence of organ dysfunction, and thus improve the quality of life of patients, Society of Colon & Rectal Surgeons of Chinese College of Surgeons of Chinese Medical Doctor Association, Section of Colorectal Surgery of Branch of Surgery of Chinese Medical Association, National Health Commission Capacity Building and Continuing Education Center Colorectal Surgery Committee, and Colorectal and Anal Function Surgeons Committee of China Sexology Association organized the discussion among relevant experts. On the basis of the 2021 edition of the Chinese Expert Consensus on the Protection of Pelvic Organ Function in Rectal Cancer Surgery, the recent evidence-based medical evidence was analyzed and summarized, and the definition, risk factors, evaluation methods, prevention and other issues of organ dysfunction after rectal cancer surgery were analyzed with reference to relevant domestic and foreign studies and combined with clinical practice. Proposed the diagnosis, evaluation and treatment of pelvic organ dysfunction in rectal cancer surgery, and finally formed the "Chinese expert Consensus on the protection of pelvic organ function in rectal cancer surgery (version 2025)".

Neoadjuvant chemoradiotherapy (NACRT) is the standard treatment for locally advanced rectal cancer (LARC), yet the pathological complete response (pCR) rates remain suboptimal. The introduction of immunotherapy has opened new avenues for LARC management, particularly in patients with mismatch repair deficiency (dMMR) or microsatellite instability-high (MSI-H) status. In this subset, anti-programmed cell death protein-1 (PD-1) monoclonal antibodies demonstrate marked efficacy, achieving high rates of clinical complete response (cCR) and pCR, thereby facilitating non-operative watch-and-wait (W&W) strategies. However, long-term outcomes and large-scale validation are still awaited. Conversely, in patients with LARC who have proficient mismatch repair (pMMR) or microsatellite stability (MSS), PD-1 inhibition alone shows limited benefit. Current research thus focuses on combinatorial approaches. Combining immunotherapy with chemoradiotherapy has shown promise in improving pCR rates in pMMR/MSS LARC, without significantly exacerbating severe adverse events. However, the discordance between post-treatment imaging assessments and pathological findings complicates clinical decision-making. Future directions include optimizing immune checkpoint inhibitor (ICI) regimens for pMMR/MSS LARC, with ongoing investigations into dual immunotherapy and anti-angiogenic synergism. Additionally, biomarker discovery, which is leveraging multi-omics and artificial intelligence (AI), will be pivotal in achieving precision therapy that balances short-term efficacy with long-term survival benefits.

Objective: To investigate the differences in clinical characteristics and prognosis between early- and late-onset rectal cancer (EORC and LORC, respectively), and to analyze the adverse factors affecting outcomes in EORC patients. Methods: This retrospective cohort and propensity score matching (PSM) study examined 904 rectal cancer patients who underwent radical resection at Peking University Shougang Hospital between 2017 and 2022. Prior to comparison, patients in the EORC group (<50 years old) and LORC group (≥50 years old) were matched at a 1:2 ratio to control for the following confounders: sex; neoadjuvant therapy; T, N, and M stage; and adjuvant treatment. Cox regression was used to identify independent risk factors for poor overall and progression-free survival (OS and PFS, respectively). Restricted cubic splines were used to analyze the association between age and clinical outcome. Results: A total of 199 EORC and 705 LORC patients were included for analysis. Prior to PSM, the proportions of patients with stage T4 [27.6%(55/199) vs.12.9%(91/705),χ²=30.12,P<0.001] and M1 disease [24.6%(49/199) vs. 15.7% (111/705),χ²=8.40,P=0.004], and the proportions of patients who received neoadjuvant [79.9% (159/199) vs. 62.3%(439/705), χ²=21.54, P<0.001] and adjuvant therapy [62.8%(125/199) vs. 50.8% (358/705), χ²=9.03, P=0.003] were significantly higher in the EORC group. Mean OS (57.8 vs. 51.9 months; P=0.011) and PFS (53.6 vs. 44.5 months; P=0.001) were also significantly longer in the LORC group. However, after PSM, the intergroup differences in OS and PFS were not significant (P=0.450 and 0.180, respectively). Multivariate Cox regression in the EORC cohort identified carcinoembryonic antigen concentration ≥5 μg/L [hazard ratio (HR), 3.79; 95% confidence interval (CI), 1.34-10.69; P=0.012] and presence of perineural invasion (HR, 7.27; 95%CI, 1.77-29.88; P=0.006) as independent risk factors for overall mortality; the only independent risk factor for cancer progression was carcinoembryonic antigen concentration ≥5 μg/L (HR, 2.56; 95%CI, 1.06-6.17; P=0.037). Restricted cubic spline analysis showed a U-shaped relationship between age and clinical outcome. After PSM, OS and PFS did not show a significant association with age in the < 60 years old group. Conclusion: Compared with LORC, EORC is more likely to be diagnosed at a later stage and has a worse outcome. Early diagnosis and timely treatment improve outcome in EORC patients.

Permanent stoma is an important method often selected in the surgical treatment of colorectal cancer, mainly including but not limited to the sigmoid colon single-lumen stoma after abdominoperineal resection. Since the stoma needs to be retained permanently, preoperative intervention for the stoma, the stoma surgical procedure, prevention and treatment of complications, and long-term postoperative follow-up are all closely related to the patient's quality of life. Under the guidance of the Colorectal Surgery Group of the Society of Surgery, Chinese Medical Association, the Colorectal Tumor Professional Committee of the Chinese Medical Doctor Association, and the Anorectal Physicians Branch of the Chinese Medical Doctor Association, led by the Stoma Study Group of the Anorectal Physicians Branch of the Chinese Medical Doctor Association and with the academic support of Chinese Journal of Gastrointestinal Surgery, experts in related fields were gathered. By drawing on the latest domestic and international guidelines and relevant literature, combining clinical practice and expert opinions, and through repeated discussions and revisions, 24 recommendations were put forward for preoperative evaluation and preparation, surgical technical operation specifications, postoperative management, complication prevention and treatment, and long-term follow-up. The aim is to provide guidance for the clinical practice of permanent stoma in colorectal cancer surgery in China.